DOI: 10.18410/jebmh/2015/667
ORIGINAL ARTICLE
RECONSTRUCTION OF POST ELECTRIC BURN DEFECTS OF UPPER
LIMB WITH DIFFERENT FLAPS
Satyajit Sahu1, A. K. Choudhary2, B. B. Nayak3, P. R. Singh4
HOW TO CITE THIS ARTICLE:
Satyajit Sahu, A. K. Choudhary, B. B. Nayak, P. R. Singh. ”Reconstruction of Post Electric Burn Defects of Upper
Limb with Different Flaps”. Journal of Evidence based Medicine and Healthcare; Volume 2, Issue 32,
August 10, 2015; Page: 4754-4759, DOI: 10.18410/jebmh/2015/667
ABSTRACT: INTRODUCTION: Post electric burn defects are difficult to manage due to deep
injury involving all the structures up to bony level. A good vascularized flap is required to
resurface the defect for preventing the complication and for reconstruction of involved structures.
AIM: Resurfacing the post electric burn defect with different flaps according to need of the
defect. MATERIAL AND METHOD: All patients of electric burn hand and fore arm defect
admitted to burn, plastic and reconstructive department of SCB Medical College &hospital,
Cuttack between January 2012 to December 2012 were included in the study. During this period
the patients were followed up at weekly interval for first 2 month, then at 1 monthly interval for
next 6-8 month. OBSERVATION: Out of 40 cases of post electric burn forearm and hand
reconstruction, 10 cases underwent groin flap cover, 6 cases underwent abdominal flap cover, 5
cases underwent cross finger flap cover 5 cases underwent free anterolateral thigh flap cover, 4
cases underwent free latissimus dorsi flap cover, 5 cases underwent first dorsal metacarpal artery
flap cover, 5 cases reverse radial forearm flap cover. All the defects were resurfaced successfully
with flaps. Four had marginal necrosis and six had wound infection. Eventually all flaps settled
well without further intervention. Due to involvement of all important tendons & nerves,
functional outcome is guarded. DISCUSSION: Hand and forearm are most commonly and most
severely affected in electric burn injury because they are mostly first part of body to come in
contact with electric circuit. Even though at initial part the injury appears to be superficial, deeper
structures like bone, tendon and neurovascular bundles are affected requiring flap cover for
future reconstruction of these structures to get functional and sensate hand. CONCLUSION:
Reconstruction of post electric burn defect of distal forearm and hand represents great challenge
due to depth of injury involving full thickness of skin and other structures like neurovascular
bundle and bones and tendons. Choice depends on size of defect, availability of local or regional
tissue, patient’s acceptance and cooperation.
KEYWORDS: Electric burn, Defects of upper limb, Flap, Reconstruction.
INTRODUCTION: Electric burn injury is defined as tissue injury following exposure to electrical
current or forces Includes: direct contact burn, arc injuries, flash, and flame burns.1,2,3 Statistics:
it contributes to 4% of admissions to burn centers & 5-10% all occupational fatalities.4 Classified
according to Voltage ˂High (>1000V) vs Low (<1000V)˃5 and type of injury (Arc,
Thermoelectrical, Flash/Flame burn).1,2,3 While considering voltage, degree of injury increases
proportionately with voltage.
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 32/Aug. 10, 2015 Page 4754
DOI: 10.18410/jebmh/2015/667
ORIGINAL ARTICLE
PATHOPHYSIOLOGY: V=IR (Ohm’s law) where R is Resistance, I is current. Resistance of skin
(dry skin=100,000, wet=1000 ohms) and internal organ (Bone, tendon, fat) = 500-1000 ohms.
Nerves, vessels, muscles are very good conductors of current. Again resistance is inversely
proportional to cross-sectional area of joints, so small joints of body like joints of foot and hand
suffers from maximum injury.6
Electric burn is also classified according to type of current (Alternative current/Direct
current), frequency (Hz), magnitude (mA), pathway. Alternative current injuries have more
morbidity and mortality than direct current.2 Hand to hand pathway (across heart) produces more
mortality.7 Standard household outlet (0.5mA, 60Hz, AC, 120V) in India produces startle
response, cutaneous burns.>10mA alternative current produces tetany, “locked-on”
phenomenon. >100mA alternative current produces loss of consciousness, asystole, and severe
tissue injury.1,2,6,8 Long-term sequelaes of electric burn include: Infection, scarring, contracture,
neurologic deficits (For weeks/months post-injury),cataracts (Opthalmologic exam in all cases of
high voltage injury), extremity complications such as neuromas, phantom limb pain.2,5 Post
electric burn upper limb defects are difficult to manage due to deep injury exposing: tendons,
neurovascular bundles, bones. Therefore a good vascularized flap is required to resurface the
defect for preventing the complication and with aim of future reconstruction.
AIM OF THE STUDY: Resurface the post electric burn hand and forearm defects with different
flaps according to need of defect.
MATERIAL AND METHOD: All patients of electric burn hand and fore arm defect admitted to
burn, plastic and reconstructive department of SCB Medical College Cuttack between January
2012 to December 2012 with different flap covers used for reconstruction. Patients were informed
about their problem, various options available to cover the defects, with the aim of future
reconstruction and informed consent taken for different flaps for cover.
OBSERVATION: We categorized our patients into different according to severity of injury they
suffered (high voltage/ low voltage) and as isolated injury of upper extremity or injury of upper
extremity associated with other defects.
Out of 40 patients of post electric burn forearm and hand defects we got 15 patients
suffering from low voltage electric burn injury, 25 patients of high voltage electric burn injury
(Table-1).
Isolated defects of upper extremity include 10 patients and defects of upper extremity
associated with other defects included 30 patients (Table-2).
All the patients we came across are male patients & within age group of 20- 40 years. In
all cases deep structures like tendon, neurovascular bundles and bones affected or exposed
requiring flap cover.
Out of 40 patients of post electric burn forearm and hand defects, groin flap given in 10
cases, abdominal flap in 6 cases, cross finger flap 5 cases, free anterolateral thigh flap 5 cases,
reverse radial forearm flap 5 cases, first dorsal metacarpal artery based flap 5 cases, free
latissimus dorsi flap 4 cases (Table-3).
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 32/Aug. 10, 2015 Page 4755
DOI: 10.18410/jebmh/2015/667
ORIGINAL ARTICLE
In two cases of groin flap cover we found proper maintenance of hand position by patient
after flap cover difficult in initial period leading to partial detachment of flap, which was re
inserted.
In one case of electric burn injury of hand, forearm (left) with loss of index finger, patient
was advised below elbow amputation by Department of Orthopedics, but now the patient had
functioning limb following free latissimus dorsi flap cover and flexor tendon reconstruction.
In all cases flaps settled well with good asthetic outcome. Functional reconstruction
planned in future according to need. Only in one case reconstruction of flexor tendon done during
this period.
Low voltage (˂1000)
High voltage (˃ 1000)
15
25
Table 1: Segregation of patients according to voltage of injury suffered 2,9,10
Isolated defects of
upper extremity
Defects of upper extremity
associated with other defects
10
30
Table 2: Segregation according to involvement with other parts
Types of flap
Number of patients
Groin flap
10
Abdominal flap
06
Cross finger flap
05
Free anterolateral thigh flap
05
Reverse radial forearm flap
05
First dorsal meta carpal artery based flap (FDMA FLAP)
05
Free latissimus dorsi flap
04
Table 3: Types of flap used and number of patients
DISCUSSION: Hand & forearm are most commonly & most severely affected in electric burn
injury because they are mostly first part of body to come in contact with electric circuit.8,9 Even
though at initial part the injury appears to be superficial, deeper structures like bone, tendon &
neurovascular bundles are affected requiring flap cover for future reconstruction of these
structures to get functional and sensate hand. Despite of all efforts complete regain of function &
sensation in hand and forearm is very difficult.10 Out of various option available for resurfacing of
defects we have to choose one option taking into consideration, availability of local tissue, size of
defect, availability of regional tissue, condition of neurovascular bundle at recipient site. In our
study we had used groin flap in most of the cases, as local tissue is not available in most cases
for resurfacing the defect, groin flap is easily available option with proper positioning of hand
without much discomfort to patient. Next easily available option is abdominal flap. Reverse radial
forearm flap can be used in cases with availability of local tissue in radial forearm territory. Cross
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 32/Aug. 10, 2015 Page 4756
DOI: 10.18410/jebmh/2015/667
ORIGINAL ARTICLE
finger flap and FDMA flap used for covering small defects over finger. Free flap can used for
reconstruction of large defects which cannot be covered by other option.
CONCLUSION: In electric burn injury of forearm & hand males are most commonly affected
with age group ranging between 20 -40 years.4,10 Resurfacing of post electric burn defect of distal
forearm and hand represents great challenge due to depth of injury involving full thickness of
skin and other structures Choice depends on size of defect, availability of local or regional tissue,
patient’s acceptance and cooperation, keeping in mind the cost effectiveness of the procedures.
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4. Kisner S, Casini V: Epidemiology of electrocution fatalities: 1998. In: Worker Deaths by
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DC, Department of Health and Human Services (NIOSH), May 1998, pp 9–19. Publication
No. 98-131
5. David N. Hendon, total burn care, 3rd edition: page: 513-519.
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NIOSH Surveillance and Investigative Findings. Washington, DC, Department of Health and
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7. Jain S, Bandi V. Electrical and lightning in-juries. Crit Care Clin 1999; 15:319 – 331.
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[Medline]
9. David P.Green, Scott W. Wolfe, Robert N. Hotchkiss, Scott H Lozin, William C. Pederson
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DOI: 10.18410/jebmh/2015/667
ORIGINAL ARTICLE
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 32/Aug. 10, 2015 Page 4758
DOI: 10.18410/jebmh/2015/667
ORIGINAL ARTICLE
AUTHORS:
1. Satyajit Sahu
2. A. K. Choudhary
3. B. B. Nayak
4. P. R. Singh
PARTICULARS OF CONTRIBUTORS:
1. Resident, Department of Plastic Surgery,
SCB Medical College, Cuttack.
2. Professor, Department of Plastic
Surgery, SCB Medical College, Cuttack.
3. Associate Professor, Department of
Plastic Surgery, SCB Medical College,
Cuttack.
4. Assistant Professor, Department of
Plastic Surgery, SCB Medical College,
Cuttack.
NAME ADDRESS EMAIL ID OF THE
CORRESPONDING AUTHOR:
Dr. Satyajit Sahu,
Markandeswar Sahi,
Radha Gobinda Lane,
Nvasaha Post,
Puri District – 752001,
Odisha.
E-mail: drsatyajitsahu1981@gmail.com
Date
Date
Date
Date
of
of
of
of
Submission: 22/07/2015.
Peer Review: 23/07/2015.
Acceptance: 30/07/2015.
Publishing: 06/08/2015.
J of Evidence Based Med & Hlthcare, pISSN- 2349-2562, eISSN- 2349-2570/ Vol. 2/Issue 32/Aug. 10, 2015 Page 4759